PRINCIPLES OF REHABILITATION

By Dr Philip Glasgow PhD, MTh, MRes, BSc (Hons), MCSP

INTRODUCTION Rehabilitation of sports injuries present the physiotherapist with a wide range of challenges. While there is often no inherent pathophysiological difference between an injury sustained by an athlete and a similar injury sustained by a non-athlete, the ramifications can be significantly diverse.

Due to the

competitive nature of sport, the physiotherapist is under constant pressure to facilitate the safe return of the athlete to competition in the shortest possible time. In order to accomplish this, the sports physiotherapist must skilfully integrate a range of therapeutic training variables to ensure that the athlete is able to work at the limit of their capacity while simultaneously ensuring that sufficient time and space is allowed for healing. An overly aggressive approach to rehabilitation may result in reinjury and delayed return to sport, while an unduly conservative approach will keep the athlete out for longer than necessary. The current article describes key components of the rehabilitation process and provides guidelines for their application in the management of the injured athlete.

In order to facilitate the effectiveness of the rehabilitation process, it is essential that the physiotherapist has the ability to apply advanced clinical knowledge to the given sporting context. In depth knowledge of anatomy and biomechanics are necessary to fully understand the mechanism of injury and potential for recurrence. Similarly, detailed knowledge of the stages of healing of different tissues such as ligament, tendon and bone will form the basis for safe exercise progression from injuries affecting these structures. In depth appreciation of sport-specific stresses and the associated injury risks involved is also necessary as is an understanding of the cultural nuances particular to each sport.

Effective planning is one of the most important aspects of rehabilitation and depends upon the integration of accurate anatomical, pathophysiological, biome- chanical and sport-specific knowledge with physical training principles. When design- ing a rehabilitation programme it is imperative that the injury is viewed in

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SPORTS REHABILITATION

PRINCIPLES AND PRACTICE

terms of its functional consequences as related to the specific sport or event of the athlete. Rehabilitation has been described as, 'the restoration of optimal form and function' (1). This definition is useful as it emphasises the amelioration of functional impairments incurred as a result of injury as the focus of management. This should be a guiding principle throughout the rehabilitation process and will necessitate a wide range of interventions prior to return to full competition.

Rehabilitation commences immediately following injury and continues beyond the athlete's return to training/competition. During the early stages the main focus of management should be directed towards resolving the clinical signs and symptoms and restoring function. Depending on the tissues affected, the severity of injury and the associated functional impairments, management in the early stages will include limiting the degree of tissue damage, controlling the inflammatory response, alleviating pain and commencing gentle controlled mobilisation.

Musculoskeletal injury can have immediate and significant detrimental effects on function. In addition to deficits experienced as a direct result of the primary injury, for example structural

instability of the knee following anterior cruciate ligament rupture, a range of secondary neuromuscular deficits may also be present and can affect structures distant from the site of injury. Injuries to ligament and joint capsule can result in the disruption of important afferent sensory input to the central nervous system, which can affect control at cortical, subcortical, cerebellar, and spinal levels (2-4). Consequently, there is a reduction in sensorimotor control due to reduced muscle reflex potentiation and motor unit recruitment, which is greatest during the first three weeks following injury.

Pain and swelling have also been shown to significantly affect sensorimotor function. Standaert and Herring (5) reported arthrogenic inhibition of vastus medialis associated with knee joint effusion. Similarly, Palmieri et al (6) have observed alteration in the activation of the peroneii in response to induced ankle joint effusion, highlighting the importance of minimising oedema in order to maintain normal neuromuscular control. One of the most effective methods of controlling oedema is the use of focal compression around the injured tissues. Wilkerson and Horn- Kingery (7) observed a 25% quicker resolu-

Figure 1: focal

compression'; a horseshoe shaped piece of felt is

applied around the lateral malleolus.

sportEX medicine 2007;32(Apr):10-16